Decision report 201103150

Summary
Ms C complained about the care and treatment provided to her late grandmother (Mrs A), by the board. Mrs A was admitted to hospital in June 2011 because of increased frailty, poor oral and dietary intake and a urine infection. She was discharged in July 2011 and died two weeks later. Ms C complained about the communication between staff and the family during Mrs A's admission to hospital. She said that, given the seriousness of her condition, staff should have been more proactive in updating the family, who only received information when they asked staff directly. Ms C also said that some staff had a negative attitude and were reluctant and ungracious when responding to requests for information. Furthermore, staff failed to make the family aware of the gravity of Mrs A's condition on discharge, which meant that the family were unprepared for her death.

We found that the amount of communication with the family appeared reasonable, but we could not establish with any certainty who prompted the discussions, or the attitude of staff during them. However, we found that the records showed that the quality of communication was variable and that there should have been more consistency in recording discussions with family members. We also found no evidence to show that Ms C and her family were told that Mrs A was likely to be approaching the end of her life.

Recommendations
We recommended that the board:
• bring our findings to the attention of relevant staff to reflect on communication with patients’ carers and families, particularly around end of life issues;
• review how communication is recorded and ensure that staff make accurate and clear records of discussions with patients’ carers and families; and
• apologise for the failures identified.